SpaMedica Poole

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• Overview
• Shared direction and culture
• Capable, compassionate and inclusive leaders
• Freedom to speak up
• Workforce equality, diversity and inclusion
• Governance, management and sustainability
• Partnerships and communities
• Learning, improvement and innovation

This means we looked for evidence that service leadership, management and governance assured high-quality, person-centred care; supported learning and innovation; and promoted an open, fair culture.

At our last assessment we rated this key question good. At this assessment the rating has remained good.

This meant the service was consistently managed and well-led. Leaders and the culture they created promoted high-quality, person-centred care.

We have not awarded this service a score for Well-led.

Find out about when we will not publish a key question score and what we look at when we assess Well-led.

We scored the service as 3. The evidence showed a good standard. The service had a shared vision, strategy and culture.

Staff knew and understood the provider’s vision and values and how they were applied in the work of their team. The provider’s senior leadership team had successfully communicated the provider’s vision and values to the frontline staff in this service. The service had a objectives pledge board ‘We all have a part to play’. Staff made a pledge to help contribute to achieving each objective. An example of this was a member of staff who committed to learning best practice from other sites to support the diversification and development of the business.

We scored the service as 3. The evidence showed a good standard. The service had inclusive leaders at all levels who understood the context in which they delivered care, treatment and support and embodied the culture and values of their workforce and organisation. Leaders had the skills, knowledge, experience and credibility to lead effectively. They did so with integrity, openness and honesty.

Leaders had the experience, capacity, capability and integrity to ensure the organisational vision could be delivered, and risks were managed. The service had inclusive leaders at all levels who understood the context in which they delivered care, treatment and support and embodied the culture and values of their workforce and organisation. The southwest structure had an allocated area manager along with a hospital manager who is the registered manager. The registered manager is the person who was registered with CQC and was legally responsible person to oversee the daily operation.

Staff told us leaders were visible and approachable. Staff overall were complimentary about the leadership team, they felt well supported and able to escalate if they had any concerns. The hospital manager was well supported by regional and national managers and received training appropriate to their role.

Leaders attended regional and national meetings with the senior leadership team where they received updates, discussed governance, performance and shared learning. Leaders had an excellent understanding of the service they managed. They could explain clearly how the teams were working to provide high quality care.

We scored the service as 3. The evidence showed a good standard. The service fostered a positive culture where people felt they could speak up and their voice would be heard.

There was a policy regarding Freedom to Speak Up (Whistleblowing). This encouraged staff to first speak with their line manager, however posters offered alternative options and routes for staff to follow if required.

Staff we spoke with felt they could speak up and were listened to. Staff felt confident to go their line manager or freedom to speak up guardian if they wanted to raise concerns. There were posters displayed in staff areas with links which encouraged staff to raise concerns if needed.

No concerns had been raised by the freedom to speak up route by staff in the year prior to our inspection.

We scored the service as 4. The evidence showed an exceptional standard. The service strongly valued diversity in their workforce. They had an inclusive and fair culture which had improved equality and equity for people who work for them.

The provider had been recognised with a platinum award for its excellent efforts in supporting and developing its employees from Investors in People. Investors in People is an internationally recognised accreditation scheme. A platinum award is the highest possible rating and reflected the work the provider led in people management and employee wellbeing. This put the provider within the top 450 companies to work for, across all sectors worldwide.

Leaders demonstrated a strong commitment to creating an inclusive workplace culture by actively supporting staff to work effectively with their disabilities and bring their whole selves to work. For example, a colleague with attention deficit hyperactivity disorder (ADHD) was encouraged and supported to deliver an awareness session on ADHD and menopause. ADHD is a condition where the brain works differently to most people. ADHD is characterised by persistent patterns of inattention, hyperactivity, and impulsivity that can affect daily functioning and development. This provided an opportunity for staff to share their lived experience, raise awareness and promote understanding of the impact of neurodiversity in the workplace. Leaders fostered an environment where individual differences were recognised as strengths and used to support learning, inclusion and wellbeing across the team.

The provider promoted equality and diversity in daily work and had an equality, diversity and inclusion policy and strategy. The strategy was a 3-year plan to create an inclusive environment where everyone felt safe, valued and respected. Equality, diversity and human rights was part of the mandatory training programme. All current staff were up to date with this training. Leadership spoke of reasonable adjustments and individualised support plans to support individual staff members.

The provider actively promoted equality, diversity and inclusion by celebrating a range of cultural, religious and awareness events throughout the year. The provider had a calendar of events for 2026 stating ‘Together we celebrate diversity, live our values, and make a difference for colleagues and patients. Events included, pride month, Ramadan, neurodiversity and mental health awareness week. The provider also has a neurodiversity forum for staff.

The provider had established arrangements to monitor and promote equality across the organisation. Gender pay gap data was regularly reported and reviewed, demonstrating transparency and supporting the identification of any disparities affecting the workforce. Equality Impact Assessments were completed at provider level and documented within individual policies. This provided assurance that equality, diversity and inclusion had been considered when developing and reviewing policies, helping to minimise the risk of unintended discrimination and ensuring compliance with relevant equality legislation.

All staff completed an annual employee survey and results from a recent staff survey showed 100% of staff said ‘people here are treated fairly regardless of their race'.

We scored the service as 3. The evidence showed a good standard. The service had clear responsibilities, roles, systems of accountability and good governance. They used these to manage and deliver good quality, sustainable care, treatment and support. They act on the best information about risk, performance and outcomes, and share this securely with others when appropriate.

There were clear and effective governance, management and accountability arrangements. There were processes to manage and review policies and procedures to make sure they were up to date. Staff were aware of policies and procedures and where to find this information. The service shared updates through monthly team and governance meetings.

There was a well-led and effective clinical governance structure with clear systems and processes. Staff understood their role and responsibilities. Each region had a governance lead who supported the hospital manager with compliance.

There were clear service performance measures to monitor, manage and report on quality and performance. When issues were identified, information technology systems were used effectively to monitor and improve the quality of care. We saw a dashboard of performance which was accessible to senior managers.

Staff followed established service-wide governance processes to ensure compliance and maintain standards. Staff consistently reviewed performance and compliance using a comprehensive audit schedule to monitor the quality and safety of the service. There was a comprehensive audit schedule set by the corporate team. Leaders took additional steps to ensure good governance and compliance and had their own monthly audits. Where compliance was below 95% the frequency of the audit was increased until compliance met the expected target.

As well as a risk register specific to the location, the service had oversight of the corporate risk register. The service risks included medicine management and equipment failure which was reviewed monthly or quarterly according to the risk score. It was clear who the responsible person was to monitor the risk and when the risk was next to be reviewed. We saw minutes of monthly team meetings where risks were discussed.

An operations scorecard was available for each location, this included monitoring of patient’s quality and safety. This was reviewed by the hospital manager and shared with staff during monthly team meetings. The overall compliance rate for June was 67.9%. Patient outcome data was submitted to the National Ophthalmology Database Audit to benchmark their performance against other service providers.

Safety bulletins from national safety organisations, such as the Medicines and Healthcare products Regulatory Agency (MHRA) were shared. Between July 2025 and April 2026 9 national patient safety alerts were issues, 2 were applicable to SpaMedica.

We scored the service as 3. The evidence showed a good standard. The service understood their duty to collaborate and work in partnership, so services work seamlessly for people. They share information and learning with partners and collaborate for improvement.

The service worked with several charities. There was a provider level partnership with a charity to support raising funds as well as improving information for patients with Age-related Macular Degeneration and signposting Macular Society services. The service was fundraising for guide dogs and local blind and cancer charities.

The local integrated care board (ICB) commissioned NHS work for the provider with key performance indictors to meet. Leaders demonstrated a commitment to engage with the ICB. Monthly contract review meetings took place to review the changes to the minimum 14 week wait time and to monitor compliance. Concerns regarding compliance were discussed and actions recorded.

The providers committed to supporting the long-term sustainability of eye care services through high quality education, surgical training and workforce development to external clinicians. The providers’ commitment was recognised externally through the Laing Buisson Award for Excellence in training.

We scored the service as 3. The evidence showed a good standard. The service focused on continuous learning, innovation and improvement across the organisation and local system. They encouraged creative ways of delivering equality of experience, outcome and quality of life for people.

Senior leaders and staff demonstrated a strong commitment to innovation and research, sharing a wide range of initiatives aimed at improving patient care and service delivery. Leaders fostered a culture of continuous improvement and encouraged the development and adoption of new ways of working to benefit patients.

We saw examples of learning and improvement focused practice that had the potential to improve patient outcomes and experience. For example, the service was trialling a patient reminder slip designed to reduce avoidable last-minute cancellations caused by changes in patients’ medical history. This initiative was introduced in response to identified issues with cancellations and reflected the service’s commitment to continuous improvement. By encouraging patients to notify the service of any relevant changes ahead of their procedure, the service could undertake any necessary planning and clinical assessments in advance. This would help to minimise disruption for patients, reduce cancellations, and support a more efficient and seamless patient journey.

People’s views and experiences were gathered and acted on to shape and improve the services and culture. Performance information was used to identify opportunities for learning. Lessons learned and good practice were shared across the organisation to support service development and drive consistent improvements in the quality of care provided.

The hospital provided simulated cataract training for junior NHS doctors. This was to support them to gain meaningful, progressive surgical experience to develop their skills.